Having a difficult time Neuro vs IM

[xenotype]

I am between Neuro and IM for specialty choice. I've read the previous threads going back a decade on this topic and they have not helped me make a decision. As I am learning much more towards neuro at this point, I have made the topic in the neuro forum.

I am halfway through third year and am rapidly approaching the point of needing to make a sure decision for residency. My favorite rotations have been stroke and SICU (I enjoyed none of the rest of surgery except SICU.) I seem to enjoy excitement, emergencies, and diagnostic complexity inpatient. Outpatient I like having patients with diagnostic complexity and plenty of time/followup to figure out their problem. I've always thought I would do IM and wasn't particularly interested in neuroscience, but the acuity, complexity, and technology involved in stroke was fascinating. I started thinking very strongly about neuro when I realized the patient I was excited the most about in FM clinic all week was a patient in status migrainosus. Academically I have broad interests across IM subspecialties and neuro.

Things I don't like: HTN, hyperlipidemia, noncompliant patients that give a rat's ass about their health, diabetes in all forms, the OR, consulting anything interesting out to someone else, ortho/MSK, ob/gyn, drunk patients

Things I surprisingly like/don't bother me: Dealing with psych patients, vague complaints, end of life issues

I am considering neurocritical care (with the ability to cover stroke) vs pulm critical care. With high burnout rates in critical care, its also important for me to have an out later in my career so I can maintain my sanity. I am leaning towards neuro because general neurology clinic sounds significantly more stimulating than pulm clinic. However, I am concerned about coming out of training with weaker procedural skills, having my management decisions dictated by neurosurgeons in the NSICU, and overall fewer job opportunities as a critical care neurologist than as pulm CCM. I generally enjoy outpatient medicine and outpatient/inpatient neurology so this isn't an easy decision to make.

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[neurologist]

Sounds like neuro-critical-care would be a pretty good match for you; the job market for that is expanding too, so I wouldn't worry too much about not finding work.

As for neuro clinic being "more interesting" than pulm clinic, well, glad you found that patient in status migrainosus so interesting since that will be about 50% of your neuro clinic. The other 50% will be noncompliant patients that give a rat's ass about their health.

 

[typhoonegator]

While there are exceptions, no one is really coming out of medical or neuro residency with great procedural skills anymore, in reference to your critical care comment. There isn't enough time between scheduled naps, and hospitals are elevating more and more procedural responsibility to the fellow/attending level for various reasons. These issues take procedures out of your hands. So don't feel like the medicine residents have a huge leg up in that department. Again, this depends on the program, and you can do electives to remediate your line placement skills prior to fellowship. The surgeons and anesthesia people both tend to have an advantage procedurally at the start of critical care fellowship.

While procedures are an important part of critical care, knowledge and the appropriate application thereof is far more important. Your smooth and quick line placement means nothing if you put the wrong drugs through it.

 

[Que]

I seem to have similar interests and concerns as xenotype. I've been pretty excited about neurocritical care ever since I "discovered" it (current MS3), but am hung by things like lifestyle. Some of the people I've spoken to (though admittedly probably not the most knowledgeable sources) seem to think that the lifestyle is pretty grueling, even post-fellowship. Do a lot of NCC practitioners, like in Pulm-CC, do a mix NCC and outpt neuro? I'm fine doing outpt neuro, I would just like to also do some NCC, maybe something like a 3:1 outpt:NCC ratio for sake of lifestyle and avoiding burnout. Is this a possible model? A similar ratio of neurohospitalist:NCC would also be appealing.

The other hang up I have is that it seems that Pulm-CC pays a lot more than NCC, but that may be too much of a thread hijack...

 

[typhoonegator]

I spend 8 weeks a year in the ICU, but I'm supported by NIH grants. Outside a research track, working 12-18 weeks a year is doable and generates a decent salary. I have clinic 2 afternoons a month seeing ICU follow-ups after discharge. There are plenty of models out there mixing NCC and hospitalist as well, but if I'm working, I'd much rather be billing critical care time. It's not really that grueling, but it is more intense than being a headache specialist. When I'm on, I get called every night, and sometimes need to go back to the hospital in the middle of the night.

Pulm-CC doesn't necessarily pay much better than NCC, depending on the case mix and patient load. If they do a lot of therapeutic bronchs and what-not, that can boost things for them, and because they don't see post-ops, the acuity level of their unit tends to on average be higher, meaning they bill more critical care time overall. However, at the institutions I've worked at, the MICU staff carry fewer patients on their roster than we do.

A big issue is that a NCCU is a luxury, while a MICU is a necessity. Departments and hospitals will do what they have to to keep a MICU running well, while a NCCU that can't justify itself financially is in much bigger trouble. Salaries can reflect that in some places.

 

[xenotype]

Thanks for all the responses; they are extremely helpful. I am definitely heading in the neurology direction at this point.

 

[deathmerchant]

Its indeed a tough decision ! One I struggled with myself at ur stage, now happily in Neuro. Also include in ur decision- making the 4 yrs of residency. Most of ur Neuro residency will not be that acute. May be 6 months, and u wont be doing much procedures or critical care stuff; it will still be traditional neuro stuff, i.e thinking. And a lot of times being able to come up with diagnoses, but no treatment. So I say if u like SICU and stuff like that u might be not like Neuro residency. But definitely Neurocritical care later on willl satisfy all ur cravings of critical care and diagnostic complexity. Again in lot of places NCC people usually just help with ICU/vent and medical management of already diagnosed/operated patients.
I just read the book "reaching down the rabbit hole" by Ropper- I think it will help u make a decision!! good luck